Governance in its most generic sense is the structure through which a body exercises its authority and performs its functions. Shared, as an adjective to governance, describes the fundamental concepts of equalitarianism, collegiality, or shared professional accountability of a particular governance structure. In the health care organization, shared governance refers to a mechanism whereby its two main accountabilities (systems and service) are aligned in a partnership model. System accountabilities are those activities and functions that increase the effectiveness of the system – functions, linkages, and roles in the health care setting. This is the work of management. Service accountabilities are the functions and activities that relate to the purpose of the organization and is the work of those who provide those services - staff nurses.

While the nurse manager's role is to obtain the necessary resources required by nursing staff to give patient care, staff nurses must exercise their authority and responsibility to determine what care to provide and how to provide the care.

A shared governance structure is the administration and deployment of the organization's services through a partnership model of managers and staff (Porter- O'Grady, Hawkins, & Parker, 1997).

However, shared governance is more than a structure. It is also a philosophy - a way of thinking that upholds the seven basic criteria for a profession in a free society (Figure 1). Shared Governance, according to Porter-O'Grady et al., (1997) is also a dynamic structure that is centered on four critical principles of fully empowered organizations: partnership, accountability, equity, and ownership. A fundamental belief behind shared governance is that staff nurses at every level in the organization should govern their practice and be included in decisions that affect their practice. Nurse managers in health organizations that employ this type of governance demonstrate a concern for both the tasks to be accomplished and the cultivation of quality partnerships among staff. They believe both are necessary for the delivery of excellent patient care and services. In this type of work setting, there is a more even distribution of influence among nurse managers and staff nurses for the work that is to be accomplished. While the nurse manager's role is to obtain the necessary resources required by nursing staff to give patient care, staff nurses must exercise their authority and responsibility to determine what care to provide and how to provide that care.

History of Shared Governance

The need to change the structure of an organizations to one that is more empowering and that enlists the active engagement and accountability of everyone in the system has its roots in the work of those who studied the changing landscape of the world of work (Abell, 1979; Argyris, 1964; Flexner, 1915/2001; Herzberg, 1966; McGregor, 1960; Naisbitt, 1982; Wade, 1967). These social scientists noted that there needed to be a direct link between the worker and the work, and that management had to perform its role differently. Wade identified a difference between governance and professional work, noting that professionalism, ethics, and practice processes should be incorporated into the structure and decision-making processes of the organization.

Influenced by the work of these individuals, change agents, and nurse leaders, Dr. Timothy Porter-O'Grady and Sharon Finnigan, in the mid 80's, piloted a nursing shared governance model that enhanced professional accountability at St. Joseph's Hospital in Atlanta, Georgia (Porter-O'Grady & Finnigan, 1984). Today, Porter-O'Grady influences contemporary health care leaders to take this governance structure a step further by creating whole-systems shared governance. Whole-systems shared governance is a structure that supports the point of service (patient care), sustaining the work processes of the organization while addressing every component part of the system, bringing nursing staff and managers together in a service partnership (Porter-O'Grady et al., 1997).

Initial Steps in the Evolution of Shared Governance

During the early 90's, Hartford Hospital, a large tertiary teaching hospital in the Northeast, significantly changed its structure and processes for the delivery of patient care and services. The Hospital's new structure, termed a Collaborative Practice Model, was funded by a national grant sponsored by the Pew Charitable Trusts and the Robert Wood Johnson Foundation known as Strengthening Hospital Nursing (Donaho & Kohles, 1996).

The new governance system formalized and demanded collaboration among all members of the organization.

Nurse leaders, Doris Armstrong and Rhonda Anderson were instrumental in this change process called Patient-Centered Redesign (PCR). PCR led to the development of the Hospital's new governance structure. This structure reaffirmed the patient as the center of all hospital activities and firmly established collaborative partnerships among managerial and clinical teams – Collaborative Management Teams, Health Care Teams, and Service Partnerships – to accomplish the Hospital's mission, goals and objectives. This new accountability-based structure replaced the former hierarchical structure with a circular design of alignment which elevated the influence of (nursing) staff as they worked side by side with managers to systematically reshape how care was to be planned, organized, delivered, monitored, and measured. In the old system, managers and staff or departments prepared for and delivered patient care and services in isolation – each intending to do their best. The new governance system formalized and demanded collaboration among all members of the organization.

Collaborative Management Teams (CMTs) are Physician-Nurse Dyads that provide managerial leadership for specific patient populations such as Women's Health Services, Cardiology, Medicine, Surgery, and Behavioral Health. Each CMT gives direction to their respective specialty Health Care Team (HCT) – a multidisciplinary team of health care workers consisting of nurses, pharmacists, physicians, physical therapists, and social workers. The HCT is responsible for creating and deploying protocols for patient care (care maps) and charting a course for performance improvement. The infrastructure to support the joint work among departments such as Dietary, Laundry, Engineering, Pharmacy, and Housekeeping back then was strengthened and evolved through quality partnerships. Quality partnerships were "formal written service standard agreements" that denoted the interdependence of all hospital departments. They served to acknowledge the pivotal importance of, and describe how the new structure of the organization was to work through relationships rather than the more traditional bureaucratic processes of managerial command and control. Today quality partnership agreements have been replaced by joint annual goal setting of all stakeholders who share in the responsibility, accountability, and authority for a specific clinical, support, or business process.

For the next ten years, Hartford Hospital's new governance structure evolved so that managers and staff had greater access to each other, participating in joint efforts to set strategy, address the needs of the community, and improve their interdependent performance. At one level of the organization – the macro level – there was indeed a greater level of collaboration and respect for the unique, important contribution of each profession or service/manager and staff. Although accountability-based governance had replaced authority-based governance in principle, there remained a nursing hierarchical structure that did not acknowledge or uphold the staff nurse's full authority, accountability, and responsibility for her/his practice. Nurse managers at various levels of the nursing hierarchy were by-and-large the decision makers for all aspects of the work of nursing. As members of the service-level Health Care Team, some staff nurses had input into a plan for care or development of care protocols (care maps). However, the entire organization of the nursing service did not reflect the rightful place of every staff nurse to have authority, responsibility, and accountability for her/his practice and the governance of activities that supported the delivery of patient care.

In addition to a steep nursing hierarchy, there were approximately thirteen committees that were in place to govern the work of nursing such as nursing education, quality assurance, and nursing management. Members of those committees and the few hospital-wide committees in which nurses participated were nurses in management positions representing the five levels of nursing governance (Vice President of Nursing, Service Nurse Director, Assistant Nurse Director, Nurse Managers, and Assistant Nurse Managers). It was clear that the staff nurse was not fully acknowledged as a key stakeholder and rightful owner of patient care and the processes that support the delivery of that care. It became apparent to nurse managers and staff nurses that the current nursing governance was not aligned in the direction to which the hospital-wide structure was evolving, and it was not in keeping with the professional practice of nursing. A task force consisting of nurse managers and staff nurses was convened to develop a shared governance nursing structure.

In its early development, shared governance at Hartford Hospital was approached more or less in a mechanistic way - heavy emphasis and attention was paid to the "structure" of the new organization.

In its early development, shared governance at Hartford Hospital was approached more or less in a mechanistic way – heavy emphasis and attention was paid to the "structure" of the new organization. Managers and staff labored over issues related to how clinical specialties and various staff would be adequately represented, or how often and long council meetings would be rather than a "philosophy" that firmly establishes parity among manager and staff in a true partnership for the delivery of patient care and professional nursing practice. In its earliest phase of shared governance, staff nurses had input at the macro-level for the work of nursing and some control over their practice through the establishment of four councils: Clinical Practice & Research, Education, Nursing Operations, and Performance Improvement. However, at the micro-level or point of service, decisions about patient care and the structures that supported that care were still made by the nurse manager. There was also variation for standards of nursing practice among the different specialty services. The extent to which the staff nurse assumed rightful control over practice was dependent upon the support and understanding of shared governance by the respective nurse manager. Not surprisingly, staff nurses and shared governance councils could not yet completely exert their legitimate authority for nursing practice because at the point of service, where practice takes place, nursing management had yet to change. It is not surprising that a pivotal part of the change toward shared governance is the changing role of nursing managers (McDonagh, 1990).

A Fuller Implementation of Shared Governance

This achievement showed that shared governance is more than structure. It is a way of being and managing. It is not what managers do, but who they are.

Flattening the nursing hierarchy, establishing clear lines for accountability for the roles in nursing, and fully deploying shared governance to the point of service became the next pivotal step in designing a system that endorsed the staff nurse's authority, responsibility, and accountability for her/his practice. It was an important fundamental step to create a nursing structure whereby the nurse manager's role changed to one of facilitator, integrator, and coordinator of the processes that support the work of the staff nurse - empowering that nurse to control her/his own practice. Achieving a change in the role of nurse managers and creating a shared governance structure that permeated the point of service ensured that the evolution of this new (whole-system) governance would take place. This achievement showed that shared governance is more than structure. It is a way of being and managing. It is not what managers do, but who they are. Nurse managers began to understand why it was important for them to give up seats on various hospital committees, seats central to patient care, to staff nurses. Staff nurses began to realize they needed to assume their rightful place of power.

Hartford Hospital and nursing governance is committed to an empowerment model for the improvement of clinical, support, and business processes. Once again, all nursing role accountabilities were revised to delineate system and service accountabilities taking a step further the process of creating parity in decision making among managers and staff nurses with staff nurses having more control over their practice. Changing and enhancing existing systems is never easy and requires the continual unfreezing and refreezing of structures and mental models of all stakeholders. Progress towards a shared governance structure has been established by the perseverance of those who believe in the need for this change and those who believe in the benefits of a collaborative practice model. In fact, as the partnership model within nursing shared governance advances, there is a concurrent advancement of the system-wide collaborative practice model. (whole-system shared governance). As nurse managers acknowledge and support the staff nurse's authority for patient care, the Collaborative Management Team is more facilitative of and less directive towards the work of the Health Care Team. Hospital-wide and nursing governance is consistent with whole-systems shared governance; it upholds a professional practice environment in which policy and controls over practice rest with the practicing professionals. A framework of whole-system shared governance provides for partnership, equity, accountability, and ownership of all stakeholders in the health care organization.

Shared Governance Today

In whole-system shared governance, the system is said to "live" where it provides service. It upholds that all members of the organization have a stake in the system, and each part of the system supports the whole. Likewise a problem in one part of the system affects the whole system because teams, not individuals are the basic unit of work.

The next significant development of...shared governance at Hartford Hospital was the belief that one part of the system cannot benefit at the expense of the whole.

The next significant development of (whole-system) shared governance at Hartford Hospital was the belief that one part of the system cannot benefit at the expense of the whole. Shared governance councils, collaborative management teams, and health care teams are enhancing their understanding of the significance of teamwork, recognizing how interdependent all roles in the organization really are when it comes to improving total hospital performance. Redundancy and waste caused by unnecessary competition or lack of coordination is removed when this kind of teamwork is in place. Today teams refer to themselves as interdisciplinary verses multidisciplinary. This acknowledges the true blending of each discipline, role, or department's contribution rather than the engagement of parallel practice of each stakeholder. In this type of environment, there is a tremendous amount of respect for the diverse and distinct contribution that each has to offer. Staff nurses practicing here are able to exercise control over their practice and share in decisions that affect their work life throughout the organization. For example, the chair of the Performance Improvement Council, a staff nurse, sits on the hospital executive level Quality Council representing Nursing. All staff nurses, not just nurses in management positions, should be empowered in this way to assume their rightful place at the decision-making table. When practicing in an organization that creates a partnership model of all stakeholders to influence and govern the systems and process of care, staff nurses must assume higher levels of accountability for their own and their colleagues' practice.

In an accountability-based governance structure there is no place for non-participation or non-ownership among the members of the organization. While it is neither feasible nor required that everyone partake in all decision-making bodies, the voice of all staff can be heard through good relations and productive communication between managers and staff, as well as through rotation of leadership/membership of councils/teams. For the staff nurse this presents the opportunity for growth and development while still maintaining a clinical role. Most recently this is being augmented by the evolution of a new Clinical Leader role for the staff nurse. These staff nurses provide leadership at the point of service in unit/service-based shared governance councils that are linked to the hospital-wide council structure. They also serve as coaches for evidence-based practice, implementation of new, automated information systems, and mentorship of new staff in their clinical specialty. Consistent with the belief that staff nurses should control their practice, this role gives legitimate leadership and position power to the staff nurse. These examples illustrate how an accountability-based governance structure, such as shared governance, supports professional nursing practice and the staff nurse's authority, responsibility and accountability for patient care and the processes that support the delivery of that care.

Barriers Along the Way

There were three main barriers in our implementation of shared governance. The first and most important was that our governance structure functioned as more of an invitation to the staff nurse to participate in this partnership model verses an expectation. Emphasis was given to educating staff nurses regarding what the roles and responsibilities of shared governance councils were rather than the philosophy of this accountability-based governance structure. In the former authority-based governance structure, the nurse manager made most of the decisions about the planning and evaluation of patient care. The new accountability-based practice shifted power regarding nursing practice, patient care, staff education, and performance improvement to the staff nurse. However, early in the implementation of shared governance, the staff nurse did not assume this level of accountability, and the nurse manager resumed this authority.

Having staff nurses scheduled out of their daily assignments to assume council responsibilities requires careful planning and understanding...that council work is just as important as direct patient care.

The second barrier was the familiar barrier of time. Having staff nurses scheduled out of their daily assignments to assume their council responsibilities requires careful planning and the understanding of their peers (and managers) that council work is just as important as direct patient care. Currently we are addressing this barrier by changing the membership of our councils to be representative of the roles of all caregivers rather than trying to represent all service/specialty areas. This will make membership on the councils smaller, yet still enable the voice of the staff nurse (and other members of the health care team) to be heard regarding planning and evaluating patient care.

The third main barrier in our evolution of shared governance still has not fully been addressed. Our initial implementation of shared governance entailed the realignment of the work of nursing to create a partnership model for care between nurse managers and staff nurses. We still must reconcile this governance structure with our Collaborative Management Team and Health Care Team structure for patient care.

Future Directions

Future steps to enhance shared governance include the following activities:

• Move from invitation to expectation – Staff nurses and managers alike must assume authority, responsibility and accountability for their respective roles.
• Clarify locus of control – Alignment of shared governance with our Collaborative Practice Model must be completed.
• Affirm our decision matrix – Not all decision can be made through consensus so it must be clear at the start how decisions will be made.
• Clarify the role of the Coordinating Council – This council must assume the role of aligning goals of the shared governance councils with other hospital-wide goals.
• Address our medical staff partnerships – Once there is clear alignment of shared governance with our Collaborative Practice Model, we will embrace whole-systems shared governance and link the entire health care team including our physician colleagues.
• Engage management – We need to remove any "shadow governance" -committees or forums that make decisions about nursing education, practice, and performance improvement outside of the council structure.
• Formalize decision making for council chairs – Since some decisions need to be made quickly, it will sometimes be necessary for the council chair to make decisions on the part of the entire membership.
• Incorporate clinical advancement for staff nurses – Clinical leaders should assume greater roles as members and leaders for our councils.
• Increase inclusion of the advanced practice nurse (APRNs) – APRNs at Hartford Hospital assume a great deal of responsibilities for patient care as delegated by our medical staff, for example by providing 24/7 coverage for our patient care units. As nurses, they are not adequately represented in our council structure, and they should be.

Summary

Implementing shared governance, or any accountability-based partnership governance, is a journey and not an end in itself. It is not something that one can do overnight, and it is not something that really has an end. As staff nurses grow in their governance role, there will always be continuing alignment of what encompasses their authority, responsibility, and accountability for patient care. Managers will undergo subsequent changes in their role as well. They will provide less management and more leadership as shared governance matures. At Hartford Hospital we have observed that nurses are now more empowered to make decisions that affect patient care. Shared governance is definitely a means to empowering staff nurses so that they have control over practice and work life.

Figure 1 - Seven Basic Criteria for a Profession in a Free Society

Well-defined and organized body of specialized knowledge Consistently enlarging knowledge and processes of education through scientific methods Education of its practitioners in an institution of higher learning Applies knowledge and practice in areas vital to human and social welfare Functions autonomously, formulates own professional policy and controls Professionally based culture – attracts individuals with intellectual and personal qualities Has some form of social and legal sanction Flexner, 1915/2001

Author

Laura Caramanica, PhD, RN
e-mail: Lcarama@harthosp.org

Laura Caramanica, PhD, RN is Vice President for Nursing at Hartford Hospital in Hartford, Connecticut, an 876-bed tertiary acute care teaching hospital. She has held the position of Vice President for Nursing since December 1999, and previously has held this position at Mount Sinai Hospital and Lawrence & Memorial Hospital, both of which are located in Connecticut. Dr. Caramanica received her diploma for nursing from Hartford Hospital's School of Nursing and a BSN from the University of Bridgeport. Her graduate degrees consist of a Master's in Nursing Administration from Teacher's College, Columbia University, and a Doctorate from the University of Connecticut, with a concentration in Administration from the School of Education. She is certified in Nursing Administration from the American Nurses Association through 2005. She has published and presented in the areas of leadership, shared governance, communication, nursing theory, and patient care in the acute care setting.

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